Health Psychology in Context

Over 25 years there has been a remarkable growth of theoretical and empirical studies in health psychology. Its theoretical underpinnings have been largely derivative, its focus primarily clinical, and its subject, the individual. Relatively little attention has been paid to the cultural, sociopolitical and economic conditions which set the context for individual health experience and behaviour. Theories which do not reflect the complex interaction of these variables are unlikely to provide a satisfactory account of individual health. Multidisciplinary efforts are needed at a community level to provide effective interventions which are relevant to the exposure groups being targeted. Health psychology needs measures which are valid and relevant to the general population regardless of culture, gender, social class or age. Putting health psychology into its cultural, sociopolitical and community context is a major priority for future development.

Freedom, Responsibility and Power: Contrasting Approaches to Health Psychology

In Health Psychology in Context it was argued that, if we are to make any sense of it, the subject matter of health psychology must be understood in the context of social, political and economic forces. That theme is continued here with a brief examination of how freedom, responsibility and power enter into the generation of conflicts, including the recent outbreak of war. The interplay of commercial and state interests in academic and health research settings is then discussed. The assumptions, values and meanings of work in health psychology are examined in that light. These are divided between four evolving approaches in health psychology: clinical, public, community and critical health psychology. A framework is presented for positioning these approaches within a system for the production of health and social care.

Socio-economic Position, Gender and Health

There is a large research literature on socio-economic inequalities in health (and explanations for these inequalities); there is also a large literature on gender differences in health (and explanations for these differences). However, the two bodies of research are rarely integrated to ask, for example, whether socio-economic inequalities vary by gender, or whether gender differences vary by socio-economic position. The separation of these two research traditions may be to the detriment of theoretical development in both of them; and in particular, asymmetrical treatment of men and women in research in inequalities in health may hinder our ability to explain the mechanisms producing inequalities. This article reviews the intersection of socio-economic position and gender, and argues for more systematic and symmetrical examination of the interaction between socio-economic position and gender in the social patterning of health.

Developing Psychosocial Theory in Health Psychology

Health psychology theories remain strongly individualistic, despite a stated commitment to the biopsychosocial paradigm. We examine some general impediments to, and strategies for, establishing health- psychology theories which have a true social dimension. These impediments stem from two sources: a style of theorizing prevalent in health psychology which we label flowcharting; and the influence of root metaphors and concepts from adjacent health sciences. Two broad strategies for combining the psychological and social in health-psychology theories are identified: integrative and transcendent. In the integrative strategy psychological constructs, such as personality and emotions, are reconstructed in a more psychosocial form. The transcendent approach involves the creation of constructs which transcend the psychosocial distinction.

Demographic Variables, Control, Stress, Support and Health among the Elderly

This article examines possible psychosocial factors that are expected to influence the health of community elderly people. A probability random sample of 240 Chinese elderly people living in a metropolitan Taiwanese city were interviewed at home. They answered questionnaires including measures for demographic variables (gender, age, marital status and education), locus of control, life stress, perceived social support and various indicators of physical and mental health. Multivariate analyses with structural modeling found that (a) age and education had direct effects on physical health; (b) stress and social support had direct effects on both physical and mental health; (c) control had a direct effect on physical but not mental health; and (d) stress, social support and control were also important mediators in the process of health and adjustment among the elderly people.

Understanding how inequality in the distribution of income affects health

Research on the determinants of health has almost exclusively focused on the individual but it seems clear we cannot understand or improve patterns of population health without engaging structural determinants at the societal level. This article traces the development of research on income distribution and health to the most recent epidemiologic studies from the USA that show how income inequality is related to age- adjusted mortality within the 50 States. (r = -0.62, p = 0.0001) even after accounting for absolute levels of income. We discuss potential material, psychological, social and behavioral pathways through which income distribution might be linked to health status. Distributional aspects of the economy are important determinants of health and may well provide one of the most pertinent indicators of overall social well-being.

Health and Socio-economic Position: A Commentary

This Special Issue focuses on health variations contingent on socio-economic position. Among the numerous reasons why health psychologists should attend to such variations are their pervasiveness, their magnitude and their continuation into better-off social groups. The latter raises the possibility that psychosocial factors may be involved. Recent data revealing that socio-economic health inequalities have increased in recent years, in parallel with increasing income inequalities in countries such as the UK and USA, provide further reason. Understanding the underlying physical, behavioural and psychosocial mechanisms is clearly an important research mission. However, effective intervention will require structural approaches that directly counter socio-economic disparity.

The inequity of inequality: egalitarian instincts and evolutionary psychology

A crucial, but unexamined, assumption motivating research into socio-economic health differentials is that such differentials are unjust. An equal distribution of health, as well as of economic resources, is regarded as the proper goal of policy. I suggest that this assumption of 'the inequity of inequality' has its basis in 'human nature'. Sustained selection pressures operating in immediate-return nomadic hunter-gatherer societies led to the evolution of 'counterdominant' behaviours in order to promote cooperation and social living. Modem humans have therefore inherited 'egalitarian instincts' that are activated when inequalities of resources (and of health) are personally encountered. This activation is qualitative, and amelioration of differentials that fall short of equality would not necessarily diminish perceived injustice. Rather than attempting to adjust the abstract statistical measures of economic and health differentials derived from population data, the goal of policy should be to address the subjective experience of the inequity of inequality at the level of individuals.

The Relationship of Socio-economic Status, Labor Force Participation, and Health among Men and Women

Using survey data from an extensive sample of Californians in the United States, we examined the relationship among indicators of socio-economic status (SES) and health for men and women in and out of the paid labor force. In contrast to data reported from the mid-1980s in which correlations among SES variables were stronger among men than among women, correlations among education, income, and occupation were similarly high among women and men. All SES variables were significantly related to health, such that as SES increased, self- reported health status increased. Multiple regression analyses demonstrated an additive effect of labor force participation and SES in predicting health among men, with main effects both of labor force participation and of income and education on health. Among women, there was an interactive effect of these variables, such that the relationship of income and of education to health was more pronounced among women who were not in the paid labor force.

The relevance of behavioural sciences in dental practice

The aim of this paper is to illustrate how knowledge from behavioural sciences is necessary and relevant in creating a successful dental practice, benefitting patients and dental professionals. There are many ways to create a successful dental practice, the products of which are the various treatments performed by dentists or dental hygienists for their patients. Advanced technologies and methods are constantly improving these treatments and thus the technical and managerial aspects of dentistry. However, the success of dental practice is not only dependent on the technique applied or the technical skills of dental professionals, but also on patients, their attitudes and behaviour and the interaction between dental professionals and patients. It is well known that the success of dental treatments (for example, periodontal, orthodontic or implants) depends on the patient's behaviour, which includes compliance with certain oral hygiene regimens or specific dental visiting patterns. The outcome of the treatment depends on both the dental professional's knowledge and skills and the patient's skills, objectives and expectations. Furthermore, dental professionals and patients should be satisfied with the treatment plan as well as the outcome. This paper argues that in order for this to happen dental professionals need additional knowledge and skills from fields outside traditional dental sciences. In order to treat patients successfully, dental professionals must understand and change or modify patient behaviour, and the knowledge necessary for this is provided by the behavioural sciences.

Social psychophysiology, social circumstances, and health

Health varies markedly with social circumstances. While we are still without a comprehensive account of the mechanisms which underlie this variation, it is clear that psychological factors are involved and that key pathways may prove to be psychophysiological. Thus, social psychophysiological research of the kind illustrated in this Special Issue is ideally placed to help unravel some of the mechanisms by which social circumstances impact on health. Nevertheless, the success of this sort of social psychophysiological enterprise most likely depends on reconceptualizing psychophysiological reactivity as a situational, or psychological exposure, concept rather than as an individual difference concept. This shifts the research goal from one of identifying individuals at risk for disease to identifying the psychological exposures that put individuals and groups at risk.

Explaining educational differences in mortality: the role of behavioral and material factors

OBJECTIVES

This study examined the role of behavioral and material factors in explaining educational differences in all-cause mortality, taking into account the overlap between both types of factors.

METHODS

Prospective data were used on 15,451 participants in a Dutch longitudinal study. Relative hazards of all-cause mortality by educational level were calculated before and after adjustment for behavioral factors (alcohol intake, smoking, body mass index, physical activity, dietary habits) and material factors (financial problems, neighborhood conditions, housing conditions, crowding, employment status, a proxy of income).

RESULTS

Mortality was higher in lower educational groups. Four behavioral factors (alcohol, smoking, body mass index, physical activity) and 3 material factors (financial problems, employment status, income proxy) explained part of the educational differences in mortality. With the overlap between both types of factors accounted for, material factors were more important than behavioral factors in explaining mortality differences by educational level.

CONCLUSIONS

The association between educational level and mortality can be largely explained by material factors. Thus, improving the material situation of people might substantially reduce educational differences in mortality.

Socioeconomic status, social environment, depression and postdischarge adjustment of the cardiac patient

In this study, we assess the adjustment achieved by patients following discharge from coronary care and the role of socioeconomic status (SES), social environment (SE), and depression in achieving that adjustment. Two hundred eighty-seven patients were enrolled. The SE into which the patients were to be discharged was rated significantly poorer for patients of lower SES, who also scored higher on depression. At 1, 6, and 12 months postdischarge, lower SES patients recorded significantly poorer levels of adjustment across a range of functioning. Predischarge depression, together with measures of SE and SES, determined 10% to 28% of the variance in 12-month postdischarge adjustment. These data suggest the importance of identifying patients at greater risk for less than optimal outcome (those lower in SES and higher in depression), and the need to address the nature of the SE in which the patient has to effect his/her recovery.

Occupational class and cause specific mortality in middle aged men in 11 European countries: comparison of population based studies. EU Working Group on Socioeconomic Inequalities in Health

OBJECTIVES

To compare countries in western Europe with respect to class differences in mortality from specific causes of death and to assess the contributions these causes make to class differences in total mortality.

DESIGN

Comparison of cause of death in manual and non-manual classes, using data on mortality from national studies.

SETTING

Eleven western European countries in the period 1980-9.

SUBJECTS

Men aged 45-59 years at death.

RESULTS

A north-south gradient was observed: mortality from ischaemic heart disease was strongly related to occupational class in England and Wales, Ireland, Finland, Sweden, Norway, and Denmark, but not in France, Switzerland, and Mediterranean countries. In the latter countries, cancers other than lung cancer and gastrointestinal diseases made a large contribution to class differences in total mortality. Inequalities in lung cancer, cerebrovascular disease, and external causes of death also varied greatly between countries.

CONCLUSIONS

These variations in cause specific mortality indicate large differences between countries in the contribution that disease specific risk factors like smoking and alcohol consumption make to socioeconomic inequalities in mortality. The mortality advantage of people in higher occupational classes is independent of the precise diseases and risk factors involved.

Hormone replacement therapy: knowledge, attitudes, and weil-being among middle-aged australian women

Use of hormone replacement therapy (HRT) is increasing, yet little is known of women's perceptions of HRT. A telephone survey examined relevant knowledge and attitudes, and psychological well-being, in 258 women aged 51 to 60 (111 HRT users, 47 previous users, and 100 never-users). Although HRT users were better informed than nonusers, knowledge was generally low. Half the HRT users could not name any hormone used in HRT, and one third could not give any reason for using HRT. Current users, however, had more positive attitudes to HRT. Groups defined by HRT usage did not differ on well-being or current symptomatology, although current and previous HRT users reported having previously experienced a higher level of symptomatology than never-users, suggesting that HRT may have provided symptom relief for those women who chose to use it. In contrast to previous research, women with a history of hysterectomy did not show more emotional distress than others. Results suggest that Australian women frequently make choices concerning HRT without adequate knowledge, and that HRT may reduce symptoms but may have little impact on psychological well-being. Optimal usage of HRT by middle-aged women will rely on a clearer understanding, both of its effects and of women's attitudes toward its use.